One of the few things upon which political parties the length and breadth of the country agree these days is the sanctity of the NHS. So Macca’s musical question of 1967: “—will you still need me, will you still feed me when I’m 64?” can be answered with a resounding ‘yes’ now that our national health service has reached—and passed—that age.

People consider it so popular and essential that the Scottish Government promised to keep raising its funding, even through this time of fiscal shrinkage: no opposition party has dared quibble. Scottish Health Boards will receive £8.645bn this financial year, rising to £9.390bn in 2014/15—an 8.6% rise.

After Greater Glasgow, Lothian Health Board receives the second-biggest chunk of that—some £1.122bn—which includes five ‘off-the-books’ PFI projects, plus a huge one on the books: the Edinburgh Royal Infirmary. It’s also been on the receiving end of unfavourable press and awkward questions both in terms of how well it is run and exactly what it does with all that public dosh.

Earlier this year, Health Secretary Nicola Sturgeon ordered an investigation into the management culture at NHS Lothian after the board was accused of manipulating waiting-times figures to meet targets.

An independent review into the management culture of NHS Lothian said interviews with staff had depicted a “wholly inappropriate style of management” that exists in parts of the health board at the centre of a waiting times controversy. Two members of staff were suspended as part of the probe. Royal College of Nursing Scotland director Theresa Fyffe said:

“The unhealthy culture that is currently being investigated at NHS Lothian has resulted in unacceptable pressure on staff. It depicts an organisation where being bullied, whilst not representing the daily experiences of the majority of staff, is common at certain levels.”

The management styles described by staff were “creating an undermining, intimidating, demeaning, threatening and hostile working environment. A number of instances of bullying, intimidation and inappropriate behaviours were alleged, both first and second-hand“. Staff anecdotes of bullying behaviour are common, with the Lothian Way often being referred to as ‘the bullying way’.

At the same time, investigating how well public money is spent in NHS Lothian is far from easy. Its Annual Reports are long on fudge that seems to satisfy a supine Audit Scotland but short on detail that then begs many questions—for example explanations for large expenditures like:

£30.1 million relating to clinical and medical negligence claims

£49.5 million revenue costs for the ERI PFI contract

£93.0 million on administrative costs (rising £13m in a single year)

In fact, it took parliamentary questions just to establish the scale of that last item—almost 10% of their total budget and growing by 15%.

No-one questions the dedication of the medical staff. But over the last couple of decades, the NHS has become bloated with administrators who perform as ‘B’ team operatives—business graduates who could not hack it in the private sector and landed cosy jobs here.

Facilities and infrastructure, especially at large teaching hospitals, attract administrators like flies. Where they do their job well, both staff and patients benefit. But where they baffle with bullshit and create the illusion of management without much corresponding substance, money gets wasted. Some examples:

Catering management thinking they were doing a grand job preparing meals: “92% of plated meals are being consumed” they reported. But all meals being delivered to other facilities were automatically counted as consumed and if a patient took one spoonful, that also counted as ‘consumed’. In fact tonnes of food were being binned.

Electricity bills were centralised “to keep them under close scrutiny”. So hospitals are heated centrally. As none of the wards or departments face any heating bill when it got too hot, staff simply open windows.

Management of hospital porters were very proud to measure efficient porter usage to their management. However, investigation found they only measured dispatching porters from a central pool to move patients around the hospital—fewer than 40% of all porters employed. The other 60% were delivering pharmaceuticals or mail or dedicated to other locations

If there is one thing worse than management unaware what is going on, it is management that thinks it knows what’s going on but has little actual clue. Administrators paid £60k to push paper around appears endemic across the NHS and not confined to NHS Lothian. However, that’s whose ineptitude resulted in two active operating theatres there being plunged into darkness last month because electricians “cut the wrong cable”.

Professor James Barbour, 59, who spent 35 years in the NHS, ten of them running NHS Lothian as Chief Executive, retired just weeks after Health Secretary Nicola Sturgeon ordered the investigation into manipulation of waiting-times figures to meet NHS Lothian targets. His abrasive dominance of meetings, including his Board, his ambition for a knighthood, and his reticence to work with any agency outside of his direct control were all legendary. In a decade, such a CEO sets the tone of the place.

Prof. Barbour and NHS Lothian may not be typical. But it is time for both the priority of patient welfare and the efficiency with which over £1bn in public money is spent (quite apart for personal ambitions) to come under proper public scrutiny. Had NHS Lothian been democratically accountable and Audit Scotland not such a limp wuss in what it regards as adequate detail in annual reports from such bodies, much of the litany above might not have survived the vigorously antiseptic effect of strong daylight.

2 Responses to Physician: Heal Thyself

Very well said, Dave. The problem grows directly from the determination of successive governments to maintain tight central control over the delivery of NHS services. I attended the most recent meeting of my local NHS Board as a member of the public and was so alarmed by the Board’s obvious incapacity to oversee and direct the work of its executive directors that I asked for, and was given, a meeting with the Chair to spell out this worry. Executive directors comprise a big chunk of the board. They are permanent, invulnerable and dominant, where non-executive directors are transitory and tentative. It is the classical recipe for arrogant incompetence, and will persist until a strong minister finds the courage to change it.